Provider Demographics
NPI:1740391127
Name:VONDERFECHT, DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:VONDERFECHT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:1 EDMUNDSON PL
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4658
Practice Address - Country:US
Practice Address - Phone:712-396-4300
Practice Address - Fax:712-396-7069
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE17681207R00000X
IA23836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731712Medicaid
IA1740391127Medicaid
NE47068731712Medicaid